Conservative management of documented neuroretinitis in cat scratch disease associated with Bartonella henselae infection

Background: Bartonella henselae has been identified as the causative agent of the neuroretinitis associated with cat scratch disease (CSD). Immunofluorescent antibody tests with good sensitivity and specificity are available to aid in diagnosis. Despite diagnostic advances, optimal management remains controversial. We present a case of documented B. henselae macular neuroretinitis managed without antibiotics and discuss antibiotic use in this condition. Methods: We examined a young woman with macular neuroretinitis and established a diagnosis of CSD. Management consisted of a review of the literature, followed by educating her about the condition and close observation. We documented the course of her disease. Results: We diagnosed neuroretinitis associated with B. henselae infection based on immunofluorescent antibody titres and clinical presentation. Our patient’s neuroretinitis resolved promptly without antibiotic therapy. Conclusions: Macular neuroretinitis in CSD can be satisfactorily diagnosed with the use of fluorescent antibodies in the appropriate clinical setting. Optimal treatment for the disease has not been established and observation combined with patient education remains an appropriate option. The self-limited nature of the disease implies that treatment studies not using controls must be interpreted with great caution. Adverse drug reactions and other iatrogenic complications can be reduced by limiting antibiotic use in settings where a meaningful treatment benefit has not been established.     

A case of cat scratch disease neuroretinitis confirmed by polymerase chain reaction

BACKGROUND: Cat scratch disease neuroretinitis is caused by infection by Bartonella henselae. To demonstrate B. henselae infection, serologic examination is commonly used, but sometimes serologic examination is not adequate for correct diagnosis. Here we present a case of cat scratch disease neuroretinitis confirmed by polymerase chain reaction in addition to serologic examination. CASE: A 55-year-old woman, presenting with headache and high fever, had noticed visual disturbance. The best-corrected visual acuity in her right eye was 0.01. Meningitis, optic neuritis and retinitis were observed and she was treated with oral prednisolone. After repeated questioning, the patient remembered being scratched by a cat. Systemic examination focusing on B. henselae infection was conducted and B. henselae-specific immunoglobulin (Ig) G, but not IgM, was detected in both serum and cerebrospinal fluid. To confirm B. henselae infection, polymerase chain reaction (PCR) analysis using cerebrospinal fluid was performed and the presence of B. henselae-specific DNA was demonstrated. From these results, we diagnosed cat scratch disease neuroretinitis and treated the patient with minocycline hydrochloride together with prednisolone. Following this treatment regimen, the patient's condition improved, and the best-corrected visual acuity in her right eye increased to 0.6 five months after the onset.CONCLUSION: The PCR technique is useful to correctly diagnose cat scratch disease neuroretinitis, if patients exhibit marginal data on B. henselae-specific antibody titer.     

Cat-scratch neuroretinitis.

BACKGROUND: Cat-scratch disease is a subacute regional lymphadenitis, usually preceded by a history of a cat scratch or exposure to kittens. The disease is caused by Bartonella henselae, and possibly Bartonella quintana, pleomorphic gram-negative rods formerly known as Rochalimaea henselae and Rochalimaea quintana. Ocular involvement is rare and typically manifests as either Parinaud's oculoglandular syndrome or neuroretinitis. Patients with neuroretinitis resulting from cat-scratch disease may be asymptomatic or experience mild-to-severe vision loss. The clinical features, angiographic appearance, differential diagnosis, and management of cat-scratch neuroretinitis are discussed. CASE REPORT: A 30-year-old white woman reported to the eye clinic with painless, decreased vision in the right eye. A diagnosis of cat scratch neuroretinitis was made on the basis of the history of cat scratch, clinical appearance, and angiographic findings. Treatment with oral ciprofloxacin restored vision to normal in 4 weeks. CONCLUSION: Painless vision loss associated with optic nerve swelling and macular star exudate should alert suspicion of systemic disease. Additional findings--including positive history of a cat scratch, lymphadenopathy, and flu-like symptoms--may indicate Bartonella henselae or Bartonella quintana infection. While treatment remains controversial, appropriate serology testing may aid in the diagnosis and management of the underlying infection.     

Cat scratch disease (CSD) in patients with stellate neuroretinitis: 3 cases

This case series describes three patients with a similar clinical picture: unilateral abrupt visual loss, optic nerve edema, and a macular star exudate. In all cases we found significant antibody titers to Bartonella henselae, the causative agent of cat scratch disease. Cat scratch disease seems to be the most common cause of stellate neuroretinitis, formerly known as Leber's idiopathic stellate retinopathy. A review of the pertinent literature shows that serologic evidence of B. henselae is sufficient to confirm the diagnosis given the low incidence of significant titers in the general population. Cat scratch disease is usually a self limiting disorder in immunocompetent patients, but treatment with doxycycline is recommended.     

Cat-scratch disease neuroretinitis

We report a case of cat-scratch disease neuroretinitis for which systemic and ocular investigations proved the responsibility of Bartonella henselae. An 11-year-old boy was referred to the hospital in November 2002 for severe visual loss in the left eye over the preceding 2 weeks. At the same time, he also developed a flu-like illness. The best corrected acuity in the left eye was counting fingers at 30 cm. Posterior segment examination on the left eye showed an optic disk edema with papillary and peripapillary hemorrhages and serous retinal detachment, mild vitreous inflammation, and two little perivascular white spots. The medical history was unremarkable except for a cat scratch on his left forearm 2 months before. Four weeks of antibiotic therapy including oral rifampin and doxycycline was used. Bartonella henselae immunoglobulin M were first detected with Bartonella henselae immunoglobulin G testing negative at this time. A 3-week serum showed immunoglobulin M seroreversion, while Bartonella henselae immunoglobulin G appeared. Other causes of optic disk edema with macular star were excluded by biological data. Bartonella antibodies to both Bartonella henselae and Bartonella clarridgeiae were detected in the cat. Ophthalmic follow-up showed progressive resorption of the neuroretinitis and the visual acuity increased to 5/10. The significance of this case report lies in the reminder that this pathology can be the cause of neuroretinitis; the prognosis can be improved by earlier treatment.     

Macular hole following Bartonella henselae neuroretinitis

PURPOSE. To report a case of macular hole secondary to Bartonella henselae neuroretinitis. METHODS. Observational case report. An 11 year-old boy presented urgently with a decrease of visual acuity in the left eye. Posterior segment examination revealed neuroretinitis attributed to Bartonella henselae. Treatment was initiated, resulting in the disappearance of symptoms. RESULTS. Follow-up consultations 7 months later showed a further decline in visual acuity secondary to a macular hole. CONCLUSIONS. Cat scratch disease is a rare pathology and is most often considered benign. Serious complications can nonetheless occur, such as neuroretinitis, choroidal nodules, and disciform keratitis. The authors report a case of sequellar macular hole. They found only one previous report of macular hole caused by B henselae, which, contrary to their case, appeared rapidly 12 days after presentation.     

Prevalence of serologic evidence of cat scratch disease in patients with neuroretinitis

OBJECTIVE: To determine the prevalence of Bartonella henselae seropositivity in patients with a clinical diagnosis of neuroretinitis. DESIGN: Retrospective, clinic-based, cross-sectional study. PARTICIPANTS: Eighteen consecutive patients seeking treatment at the Casey Eye Institute from November 1993 through November 1998 who had neuroretinitis. METHODS: The billing and photographic records of the Casey Eye Institute were searched for patients with a primary or secondary diagnosis of neuroretinitis or Leber's idiopathic stellate neuroretinitis. Charts were then reviewed to determine the results of B. henselae antibody titers and other pertinent clinical information. MAIN OUTCOME MEASURES: Results of B. henselae serologic testing. RESULTS: Fourteen of 18 patients with neuroretinitis had serologic studies. Nine of the 14 tested patients (64.3%) were found to have elevated IgM or IgG for B. henselae, suggesting current or past infection. Patients with positive serologic analysis results tended to have worse vision at presentation. There were no other obvious differences between seropositive and seronegative groups in this study, including duration or quality of recovery. CONCLUSIONS: At our tertiary care ophthalmology institution, most tested patients with neuroretinitis had evidence of past or present cat-scratch disease based on positive serologic analysis for B. henselae, a much greater prevalence than is expected to be found in the general population or in patients with idiopathic uveitis. Further study is indicated to clarify the prevalence of cat-scratch disease in neuroretinitis and the role and efficacy of antibiotics in treatment.     

Ocular manifestations of cat-scratch disease.

Bartonella henselae has only recently been isolated, characterized, and found to be the principal cause of cat-scratch disease (CSD). The availability of specific serologic investigations has allowed the recognition of a spectrum of ocular CSD syndromes that previously were ill defined and considered idiopathic. The primary inoculation complex causing regional lymphadenopathy is represented in the eye by Parinaud's oculoglandular syndrome; B. henselae is the most common cause. Leber's neuroretinitis has been identified for 80 years, and new data suggest that it is commonly a manifestation of CSD; the extent of the association remains to be determined. CSD optic neuritis is also described. The vitreoretinal manifestations include anterior uveitis, vitritis, pars planitis, focal retinal vasculitis, a characteristic retinal white spot syndrome, Bartonella retinitis, branch retinal arteriolar or venular occlusions, focal choroiditis, serous retinal detachments, and peripapillary angiomatous lesions. The pattern of ocular disease in AIDS-associated B. henselae infections is poorly delineated; unusual manifestations include conjunctival and retinal bacillary angiomatosis. The benefit of antimicrobial therapy for CSD in immunocompetent individuals has been difficult to establish, partly because most infections are self limited. Empirically, azithromycin, ciprofloxacin, rifampin, parenteral gentamicin, or trimethoprim-sulfamethoxazole provide the best therapeutic choices to minimize damage to the eye.     

Presumed ocular bartonellosis

BACKGROUND: The spectrum of diseases caused by Bartonella henselae continues to expand and ocular involvement during this infection is being diagnosed with increasing frequency. METHODS: The clinical features and visual prognosis for 13 patients with intraocular inflammatory disease and laboratory evidence of bartonellosis were investigated. There were nine patients with neuroretinitis and four with panuveitis with positive antibody titres against B henselae determined by an enzyme immunoassay (IgG exceeding 1:900 and/or IgM exceeding 1:250). RESULTS: Positive IgG levels were found for eight patients and positive IgM levels for five. Despite animal exposure of 10 patients, only two (IgG positive) cases had systemic symptoms consistent with the diagnosis of cat scratch disease. Pathological fluorescein leakage of the optic disc was observed in all affected eyes. At 6 months' follow up, 3/18 (17%) affected eyes had a visual acuity of less than 20/100, owing to optic disc atrophy and cystoid macular oedema. 12 patients (17 eyes) were treated with antibiotics; visual acuity improved two or more Snellen lines for 9/17 (53%) eyes. CONCLUSIONS: The possibility of B henselae infection should be considered in patients with neuroretinitis and panuveitis (especially in cases with associated optic nerve involvement) even in the absence of systemic symptoms typical for cat scratch disease.     

Pattern Visual Evoked Potentials in Eyes with Disc Swelling due to Cat Scratch Disease-associated Neuroretinitis

Purpose: To evaluate optic nerve function by pattern visual evoked potentials (VEPs) in eyes with optic disc swelling due to neuroretinitis associated with cat scratch disease (CSD). Methods: Four eyes of four patients with marked optic disc swelling resembling optic neuritis but diagnosed serologically as CSD received systemic steroid treatment. VEPs elicited by black and white checkerboard stimuli created on a TV monitor were recorded before the treatment. Results: The visual acuity (VA) in the affected eyes was decreased to 20/50 in two eyes and finger counting in two eyes at their initial visits. Ophthalmoscopic examination revealed neuroretinitis characterized by severe optic disc swelling, chorioretinal exudates, and macular edema in all eyes. Anti-Bartonella henselae serum antibody was markedly elevated in all patients confirming the diagnosis of CSD. The P100 of the transient VEPs was only mildly reduced without a delay in the implicit times in three eyes and only slightly delayed in the other eye. The steady-state VEPs were mildly reduced in two eyes and phase-reversed in other two eyes. The VA fully recovered after systemic steroid treatment in all patients. Conclusions: Although all examined patients showed marked swelling of the optic disc and visual decrease, the pattern VEPs were not affected as severely as in idiopathic optic neuritis. However, the degree of change of the pattern VEPs varied among patients.     

Optic neuropathy secondary to cat scratch disease: case report

Optic neuropathy due to cat scratch disease is a relatively infrequent occurrence associated with macular star formation and is characterized by sudden painless loss of vision mostly unilateral. Bartonella henselae is well recognized as the etiologic agent in cat scratch disease. Ocular complications of the disease occur in up to 10% of patients and include neuroretinitis. Ocular bartonelosis is usually self-limited with complete or near-complete recovery of vision in otherwise healthy patients. A case of a boy with neuroretinitis caused by B. henselae is reported.     

Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis

Purpose

To describe the macular findings on optical coherence tomography (OCT) in patients with cat-scratch disease (CSD) neuroretinitis.

Methods

Medical records of all patients diagnosed with CSD neuroretinitis at the Tel Aviv Medical Center between April 2006 and May 2010 were retrospectively reviewed. All patients underwent Stratus OCT macular examination.

Results

Eight eyes of seven patients with confirmed CSD neuroretinitis, (mean age 33±9.9 years, range 6–48 years) were included in the study. All patients presented clinically with optic nerve swelling and macular edema or macular exudates. OCT demonstrated flattening of the foveal contour, thickening of the neurosensory retina, and accumulation of subretinal fluid (SRF) in all studied eyes. Retinal exudates appeared as multiple hyper-reflective foci in the outer plexiform layer. The average central macular thickness was 460 μm (range 170–906 μm) and the average maximal retinal thickness was 613 μm (range 387–1103 μm), at presentation. The macula appeared normal on repeated exams during follow-up.

Conclusion

Similar OCT findings were demonstrated in patients with CSD neuroretinitis. SRF was found in all eyes, although was not visible on clinical examination or fluorescein angiography. OCT may be used as an adjunct imaging tool in the diagnosis and follow-up of patients with CSD neuroretinitis.     

Bartonella henselae infection presenting as a unilateral acute maculopathy

BACKGROUND: The purpose of this article is to report an unusual ocular manifestation of cat scratch disease (CSD) presenting as a unilateral acute maculopathy (UAM). We describe and review the clinical, laboratory, fluorescein angiography (FA), indocyanine green angiography (ICG) and optical coherence tomography (OCT) records of a patient with CSD. HISTORY AND SIGNS: A 30-year-old Chinese woman presented with a painless progressive visual loss affecting her left eye. Fundus examination of the left eye disclosed rare vitreous cells and a deep-creamy choroidal macular lesion with satellite foci of choroiditis. THERAPY AND OUTCOME: FA revealed an early hypofluorescence of the lesion, becoming progressively hyperfluorescent with a leakage on the late phase. The ICG disclosed an early hypofluorescence of the macular lesion with a mild staining of its periphery on the late frames. Hypofluorescent satellite lesions were visible both on the early and late frames. The OCT disclosed a serous retinal detachment at the level of the whitish lesion. Serologies for Bartonella henselae (BH) became positive (IgG 1: 512, IgM < 1:20) confirming an active or recent infection. CONCLUSIONS: Ocular manifestations of CSD can appear as a UAM with satellite lesions. CSD should be ruled out in patients manifesting such clinical features.     

玻璃体内注射曲安奈德治疗继发于IRVAN的黄斑水肿

目的:报告玻璃体内注射曲安奈德对特发性视网膜炎、血管炎、动脉瘤及视神经视网膜炎(IRVAN)所致的黄斑水肿的治疗效果。方法:病例报告。结果:患者诊断为特发性视网膜炎、血管炎、动脉瘤及视神经视网膜炎导致的伴有视力丧失的继发性黄斑水肿。玻璃体内注射曲安奈德后黄斑水肿减轻,视力显著改善。结论:以前的报告建议采取全视网膜光凝,玻璃体切除术及全身和眼部类固醇治疗。对于继发于IRVAN的黄斑水肿和血管炎,玻璃体内注射曲安奈德是一种安全有效的治疗方法。     

Optic disk edema associated with peripapillary serous retinal detachment: an early sign of systemic Bartonella henselae infection

PURPOSE: To describe optic disk edema associated with peripapillary serous retinal detachment as an early sign of systemic Bartonella henselae infection. METHODS: Multicentered, retrospective case series. RESULTS: Five women and two men presented with optic disk edema producing peripapillary serous retinal detachment. Each patient had a markedly elevated serum anti-B. henselae antibody titer. Patient age ranged from 11 to 44 years, with a mean and median of 26.6 and 28 years, respectively. The time from the onset of systemic symptoms to the onset of visual symptoms varied from 3 days to 1 month. The peripapillary serous retinal detachment resolved within 1 to 3 weeks in each case, producing a macular star in four of seven patients. Initial vision was 20/200 or worse in five of seven patients and improved in four of these five patients to 20/30 or better. CONCLUSIONS: Systemic B. henselae infection should be considered in patients who develop optic disk edema associated with a peripapillary serous retinal detachment, even in the absence of classic neuroretinitis with a macular star.     

Neuroretinitis associated with cat-scratch disease in Japanese patients

PURPOSE: To clarify the prevalence and clinical profile of neuroretinitis associated with cat-scratch disease (CSD) in Japan. METHODS: Japanese patients were searched using a computer web site, Japana Centra Revuo Medicina. Location of patients, medical history, systemic and intraocular findings, treatments and visual outcome were examined. RESULTS: We reviewed 15 eyes of 14 patients, including our own case. Incidences of the disease were more common in summer than in winter and presented in the warmer parts of Japan. All patients had been previously healthy and had been exposed to cats or flea bites. Of the 14 patients, 13 (93%) had febrile illness and seven of these (54%) had lymphadenopathy. Uveitis and macular stars were observed in 11 of 15 eyes (73%). Most patients were treated with antibiotics and systemic steroids and visual prognoses were good. CONCLUSIONS: The clinical features of CSD-associated neuroretinitis in Japan are similar to those in other countries. Its distribution may correlate with the prevalence of Bartonella henselae-seropositive cats in Japan.     

玻璃体内注射曲安奈德治疗继发于IRVAN的黄斑水肿

目的：报告玻璃体内注射曲安奈德对特发性视网膜炎、血管炎、动脉瘤及视神经视网膜炎（IRVAN）所致的黄斑水虢曲治疴效栗,方法：病例报告。结果：患者诊断为特发性视网膜炎、血管炎、动脉瘤及视神经视网膜炎导致的伴有视力丧失的继发性黄斑水肿。玻璃体内注射曲安奈德后黄斑水肿减轻,视力显著改善。结论：以前的报告建议采取全视网膜光凝,玻璃体切除术及全身和眼部类固醇治疗。对于继发于IRVAN的黄斑水肿和血管炎,玻璃体内注射曲安奈德是一种安全有效的治疗方法。     

Cat-scratch disease neuroretinitis diagnosed by a polymerase chain reaction approach

PURPOSE: To assess the value of polymerase chain reaction in the diagnosis of cat-scratch disease neuroretinitis without conclusive serology. METHODS: Interventional case report. A 13-year-old girl developed a right neuroretinitis 2 months after a cat scratch. Despite the lack of accompanying features, an infection by Bartonella henselae was suspected and a systemic check-up was performed. RESULTS: Serologic results excluded other proposed origins but were insufficient in making the diagnosis because of low B. henselae specific IgG level in serum. A polymerase chain reaction analysis for B. henselae DNA in a small axillary lymphadenopathy aspirate enabled us to achieve a definitive diagnosis of cat-scratch disease. CONCLUSION: Polymerase chain reaction is a valuable method of diagnosing cat-scratch disease when serology is considered negative or borderline.     

An uncommon presentation of Bartonella-associated neuroretinitis.

BACKGROUND: This article documents a case of neuroretinitis initially presenting with ocular pain, 20/20 visual acuities, optic disc edema, and macular serous detachment without macular star formation in the absence of a history of exposure to pets or cats or symptoms suggestive of Bartonella infection. This initial clinical presentation appeared unilateral, but later became bilateral. CASE REPORT: Physical and neuroophthalmologic consultation, neuroimaging studies, blood chemistry, and serologic analysis were requested. Positive serologic (IGG) titers to Bartonella henselae and Bartonella quintana were detected. Treatment was instituted initially with oral tetracycline (250 mg) qid and subsequently with doxycycline (100 mg) bid and prednisone (20 mg) qd. CONCLUSION: Bartonella infection may cause optic disc edema and serous detachment without macular star formation. This presentation may occur without the generally characteristic signs and symptoms of Bartonella-associated neuroretinitis. A bilateral involvement may follow an initial unilateral presentation during the affliction period of this disorder.     

Multifocal chorioretinitis, papillitis, and recurrent optic neuritis in cat-scratch disease

To evaluate the causative factor for multifocal chorioretinitis, papillitis, and recurrent optic neuritis. A 41-year-old patient presenting multifocal choroiditis, papillitis, and recurrent optic neuritis was evaluated with funduscopy, angiography (FA), optical coherence tomography (OCT), visual evoked potentials (VEP), and numerous blood laboratory tests. FA and OCT showed multifocal pigment epithelial detachments. VEP showed typical changes for optic neuritis and papillitis. Indirect fluorescent antibody assay disclosed Bartonella henselae. Although cat-scratch disease frequently presents with optic neuritis or neuroretinitis, additional multifocal chorioretinal lesions associated with serous pigment epithelial detachments may occur. In case of recurrent episodes, a detailed laboratory work-up is mandatory to define the appropriate diagnosis and treatment.